Hilton Head Heart, P.A. 
Hilton Head Heart 
25 Hospital CenterBlvd. Suite 302-305 
Hilton Head Island, SC 29926 
Tel. (843) 682-2800 
Fax (843) 682-2812 

Date:_____________________________ 

Patient Full Name: ___________________________________________
Social Security No.: __________________________________________

TO WHOM IT MAY CONCERN: 
The undersigned hereby authorizes 

Dr.___________________________ 

Dr.___________________________ 

Dr.___________________________ 

To release to Hilton Head Heart any and all information and all medical records of the undersigned and to freely discuss my care and treatment. A photocopy of this Authorization shall have the same force and effect as an original. This authorization is no way limited by time nor medical subject. Thank you in advance for any assistance you may provide. Very Truly Yours, 

Signature______________________________________ 
Printed Name __________________________________ Date:___________________